GLOBAL DENTAL RELIEF DONATIONS

Please fill out the form below and options for paying will be displayed. Credit card is via paypal.

DONATION FORM:
1)  Yes, I want to contribute:
Please check one.

$   50             Care for 6 children
$ 100             Care for twelve children
$ 500             Care for 60 children
$1000            Dental supplies to serve 2000 children
$2500             New portable dental unit
$5000             Complete dental station

Type of payment: PayPal Check Select One

Global Dental Relief is a 501(c ) 3 charitable organization.

2)  Please send more information.  I am interested in volunteering as a:   Select One Dentist Dental Assistant Hygienist Non-medical   

3)   I would like to volunteer in Select One Nepal Vietnam Ladakh, India Guatemala

4)   I want to help in other ways:
Donating Supplies
Recruiting Volunteers
Administrative Support in the US
Other:  please specify

5)  Contact information:

First Name:		*
Last Name:		*
Address:
City:
State:
Zip:
Email Address:		*
Telephone:
Comments:

THANK YOU FOR YOUR SUPPORT!